Nine-year acute coronary syndrome trends in a regional centre distant from a national cardiac centre: implications for healthcare equity and access

Background Acute coronary syndrome (ACS) registries are largely derived from national referral centres. Data from regional urban centres distant from national cardiac hubs remain limited, particularly in Southeast Asia, with implications for healthcare equity. Purpose To assess nine-year trends in ACS presentation, coronary anatomy and revascularisation in a regional centre remote from a national cardiac institute, and to evaluate age–sex disparities. Methods We retrospectively analysed 3,316 consecutive ACS admissions over nine years. Patients were stratified using sex-specific thresholds (young: ≤45 years men, ≤55 years women). Clinical characteristics and angiographic findings were compared. Multivariable logistic regression identified predictors of STEMI. Results Mean age was 55.7±8.8 years; 81.2% were male. STEMI accounted for 41.1% of presentations and remained proportionally stable across study years. Cardiometabolic burden was high: hypertension 74.7%, dyslipidaemia 58.7%, diabetes 34.1% and active smoking 58.4%. Compared with younger patients (n=562), older patients (n=2,754) had significantly higher prevalence of hypertension (75.7% vs 69.8%, p=0.004), dyslipidaemia (59.5% vs 54.6%, p=0.035), multivessel disease (69.2% vs 57.1%, p<0.001) and left main involvement (21.0% vs 13.3%, p<0.001). STEMI proportion did not differ between age groups (41.0% vs 41.5%, p=0.875). Sex-stratified analysis showed marked disparities (interaction p<0.001). Young men had the highest STEMI proportion (51.4%) compared with older men (42.8%), young women (24.3%) and older women (30.5%) (p<0.001). Smoking was most prevalent in young men (72.2%, p<0.001). Conversely, diabetes was disproportionately common in young women (43.7%) compared with young men (26.7%) and older women (40.3%) (p<0.001). Multivessel disease and left main involvement were most frequent among older men (71.7% and 21.9%, respectively; p<0.001). In multivariable analysis, male sex (OR 1.57, 95% CI 1.28–1.92, p<0.001) and smoking (OR 1.76, 95% CI 1.51–2.05, p<0.001) independently predicted STEMI, whereas hypertension was inversely associated (OR 0.61, 95% CI 0.52–0.72, p<0.001). Age, diabetes, dyslipidaemia and multivessel disease were not independently associated with STEMI. Percutaneous coronary intervention was performed in 67.6% of cases. Conclusion Despite practice outside a tertiary cardiac hub, this nine-year registry demonstrates a persistently high STEMI burden and frequent multivessel disease. Distinct phenotypes emerge: smoking-driven premature ACS in young men and a disproportionate diabetes burden in young women. Geographic remoteness does not lessen disease complexity and underscores the need for equitable invasive capacity and targeted prevention within regional health systems.